Monitoring cerebral oxygenation in traumatic brain injury

https://doi.org/10.1016/S0079-6123(06)61014-5Get rights and content

Abstract

Ischemia is a common problem after traumatic brain injury (TBI) that eludes detection with standard monitoring. In this review we will discuss four available techniques (SjVO2, PET, NIRS and PbrO2) to monitor cerebral oxygenation. We present technical data including strengths and weaknesses of these systems, information from clinical studies and formulate a vision for the future.

Introduction

Treatment of patients with severe traumatic brain injury (TBI) is largely focused on the prevention of secondary insults. Standard monitoring consists of measuring intra cranial pressure (ICP), (mean) arterial blood pressure (MAP) and thus calculating the cerebral perfusion pressure (CPP=MAP−ICP). This has led to ICP and CPP driven treatment protocols (Rosner et al., 1995; Nordstrom, 2005). However these measurements do not give further information on the existence of ischemia which is common in post mortem studies after TBI (Graham et al., 1978, Graham et al., 1989). Much effort has gone into the development of extra monitoring of the injured brain, so called multi modal monitoring (Unterberg et al., 1997; Meixensberger et al., 1998; Mulvey et al., 2004; De Georgia and Deogaonkar, 2005; Vespa, 2005). This review will focus on monitoring oxygenation in the injured brain. We will discuss the available technologies with special emphasis on brain tissue oxygen tension measurement, their (dis)advantages, the available clinical data with results of interventions with CPP and respiratory variations and will conclude summarizing our view of the future with these new technologies.

Section snippets

Global vs. focal monitoring

The different measurement modalities have different working areas. Some work very focally (e.g. brain tissue oxygen tension measurement) others globally (e.g. jugular bulb oxygenation). This leads to differences in their use and interpretation of their values (Sarrafzadeh et al., 1998; Gopinath et al., 1999; Bellander et al., 2004; Engstrom et al., 2005). The advantage of a global measurement is the information on a large part of the injured brain, more so because most treatments in TBI are

Jugular oximetry

Low SjVO2 values (below 50–55%) are related to poorer outcome (Gopinath et al., 1994; Fandino et al., 2000; Perez et al., 2003). The same holds for values higher than 75% (Cormio et al., 1999; Macmillan et al., 2001). Others have challenged these classic cut-off values after measurements in patients with Cushing syndrome (44.7–69.5%) (Chieregato et al., 2003). A limited improvement as opposed to clear improvement in increased AVDO2 after treatment is also related to poorer prognosis (Le Roux et

Technology comparisons

SjVO2 values correlate with IBV, defined as the area with CVO2 content ⩽3.5 ml/100 ml as measured by PET scan, with SjVO2 <50% occurring at IBV at 13±5% (Coles et al., 2004a).

In a study in 14 patients NIRS detected twice as many events as SjVO2 monitoring although the clinical significance of this is not known (Kirkpatrick et al., 1995). Another study found poor correlation between NIRS and SjVO2 monitoring even with SjVO2 desaturations below 55% (Lewis et al., 1996). In a study in 60 children

Summary and conclusions

ICP and CPP measurements alone are inadequate for detecting ischemia. The above-mentioned techniques can provide valuable information on oxygenation. An ideal technique (non-invasive, continuous, reliable and easy to use on the ICU) does not exist. To gain maximal insight the combination of a local and global monitor should suffice. However the advantages in outcome with extra measurements or targeted treatment have not yet been unequivocally proven. Any effort to do so should be stimulated and

Acknowledgments

The work of Dr. Haitsma is supported by NWO grant: 920-03-130. The Department of Neurosurgery, EMC, has received in natural support of research in neurocritical care from GMS mbh. (Kiel, Germany) and Codman/Johnson & Johnson (Raynham, MA, USA).

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